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Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign The Application. <br /> FOR OFFICE USE: APPLICATION <br /> (For Non-Transferable, Revocable,Suspendable) <br /> ENVIRONMENTAL HEALTH PERMIT PUMP&WEl.l. <br /> (COMPLETE IN TRIPLICATE)` �..Z/ �' t/q,l ;./-WATER QUALITY 2 �� �� 1 <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is <br /> made in compliance with San Joa uin County Ordinance No.11362 and the rules and regulations of the San Joaquin Local Health District. + <br /> Exact Site Address Xt [✓;� int r � Z,6 p er( City/Town <br /> Owner's Name- 042 Alknm F_/l es�f h' Phone 3 '� 3/C <br /> Address 0 � " City P 7n x✓ <br /> Contractor's Name LAiLf I' <br /> t�j U ILL/) a _License 4—a T61 BusinessP hone_4z6v- zlr3 f _ <br /> Contractor's Address -Emergency Phone <br /> Is Certificate of Workman's Compensation Insurance n File With SJLHD? Yes 4r-- No \\tt <br /> TYPE OF WORK (CHECK): NEW WELL❑ DEEPEN ❑ RECONDITION❑ DESTRUCTION❑ "" <br /> WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIRED-- <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank d""— C_ Sewer Lines IPU c:F Pit Privy �fvG1i� <br /> Sewage Disposal Field—,$,,L'OV Cesspool/Seepage Pit lLlry "P Other <br /> Property Line " Private Domestic Well Public Domestic Well <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation" <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing ;' s <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> &RRIGATION ❑ GRAVEL PACK Depth of Grout Seal 4 <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: N <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: Eg—tate Work Done 7 0? <1 <br /> DESTRUCTION OF WELL: Well Diameter Approximate Depth `. <br /> Describe Material and Procedure <br /> �f <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County i <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> b <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work forwhich this <br /> permit is issued, I shall employ persons subject to workman's compensation laws of California." <br /> t, <br /> 1 will call for a Gr t Inspection prior to grouting and a final inspecti <br /> Signed X Title: �°,�X-/l Date: i <br /> d (Draw Plot Plan on Reverse Side) <br /> FOR DEPARTMENT USE ONLY <br /> PHASE <br /> Application Accepted By 2` Date d 2 <br /> Additional Comments: <br /> Phase II Grout Inspection r!P/ I�Fal pection <br /> r.;, ,� Inspection By 71 Date Inspection By �" Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ JuVy 1 &Received Sy July 31 ! <br /> I BILLING .. REMITTANCE $ REMIT <br /> BASE EXPLANATION DATE DATE REMITTED AMOUNT DUE CHECKED <br /> AMOUNT <br /> FEE lMI. �P 5 <br /> LESS <br /> PRORATION - <br /> PLUS _ <br /> PENALTY . -� <br /> OTHER 4 <br /> OTHER. <br /> � i F <br /> Received by Date +,::. Receipt No. Permit No. .Issuance Date` Mailed l]ehvered f <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.;P.C.Box 2009 STOCKTON,CA 95201 <br />